A Simple Method Is Used to Identify PVI‐Responsive Patients With Persistent Atrial Fibrillation: Electrical Cardioversion and Noninduction Before Procedure

Background Pulmonary vein isolation (PVI) demonstrates less efficacy in persistent atrial fibrillation (PersAF) compared to paroxysmal AF. Although recent multiple‐center RCTs have shown that additional ablation, except for the ethanol intervention of the Marshall vein, has not significantly benefited in persistent AF. Therefore, the most important issue is how to identify PVI‐responsive PersAF. Objectives This exploratory cohort study assessed a novel direct current cardioversion–electrophysiological study (DC‐EPS) protocol before ablation, and evaluated whether inducibility can be guided by a PVI procedure. Methods In this prospective cohort study, patients were classified as Protocol‐Negative (AF non‐inducible post‐cardioversion) and Protocol‐Positive group (failed cardioversion, spontaneous AF recurrence within 5 min, or induced AF). PVI alone was done in the Protocol‐Negative group, while PVI with adjunctive line ablation (Roof/MI/CTI lines) was performed in the Protocol‐Positive group. The procedure success endpoint is freedom from atrial arrhythmias > 30 s without antiarrhythmic drugs within 12 months. Results Over the 12‐month follow‐up, 41 of 48 patients (85.4%) in the Protocol‐Negative group and 37 of 61 patients (60.7%) in the Protocol‐Positive group remained free from ATA. Arrhythmia‐free survival was significantly higher in the Protocol‐Negative group (HR = 0.326; 95% CI, 0.140–0.756; p = 0.009). After multivariable adjustment, the recurrence risk remained lower in Protocol‐Negative patients (adjusted HR 0.328, 95% CI 0.138–0.779, p = 0.012). Protocol‐Negative patients exhibited preserved cardiac architecture (left atrial volume: 134.5 vs. 151.8 mL, p = 0.022) and less fibrosis (low‐voltage area: 0 vs. 1.3 cm², p < 0.001). Conclusions Patients with DC‐EPS–defined Protocol‐Negativity have an excellent PVI responder. These findings suggest that PV antrum isolation may be enough in the initial procedure, and require a multi‐center RCT for further investigation.